Prior Authorization Request
for Advanced Imaging Checksheet
Puget Sound contracted providers (King, Kitsap, Lewis, Mason, Pierce, Snohomish,
Thurston counties): Fax to Radiology Appointing Center: 206-988-2906
All other providers: Fax to Pre-Service Department toll-free: 1-888-282-2685
This form can be used by providers who cannot access Group Health’s online Referral Request tool
at MyGroupHealth for Contracted Providers at ghc.org or through OneHealthPort.com.
Patient Name Member #
Presenting Diagnosis Code (ICD-9) Date of Birth
Ordering Provider Tax ID #
Clinic Contact Phone # Fax #
Referred To Provider/Facility Phone #
Date Procedure Scheduled (if applicable) On The Job Injury? Yes No
(Circle one of the code numbers below)
CTA Chest: 71275
Aorta/great vessel evaluation
A) Subclavian steal suspected
A) SVC suspected
A) Noeplastic involvement suspected
A) Aortic aneurysm—evaluate
A) Aortic dissection—evaluate
A) Congenital abnormality suspected
A) Vision symptoms, suspect posterior ischemia
D) Other:
Pulmonary artery evaluation
A) Pulmonary embolism suspected
D) Other:
Surgical evaluation
A) Pre-op assessment
A) Post-op assessment
D) Other:
Other
D) Other:
Provider Checklist: CTA Chest Page 1 of 1 Revised 10/02/2009